The ‘New Normal’ Nursing

Entering the ninth month of what is deemed as the new normal, has reinforced the reality that COVID-19 has been the highlight of this year. Our lives have changed because of this pandemic. It became the decisive factor in several facets of our living. Lockdown was implemented more than once. For most of us, the year flew by like a blur.

One of the greatly affected sectors is healthcare. As the first few cases were confirmed in the British Isles, changes in rendering patient care were observed. It was a period of much uncertainty and anxiety. It was still a disease that we knew little about. Lots of questions needed answers. Policies changed as quickly as new information was disseminated.

In the neonatal unit, since we look after vulnerable patients, more precautionary measures have been set in place. Safety for everyone has always been a priority. Wearing masks and social distancing became mandatory. We also had to undergo fit testing for FFP masks in case a patient with COVID-19 will be placed in our care. The shift towards this new way of nursing was not easy. Having a mask on for 12 hours is not a comfortable experience and made communication slightly tricky, not to mention for the colleagues who had to don full PPE when caring for query COVID-19 babies. Some colleagues also had to self-isolate or shield. There were days when the supplies had to be carefully utilised.

The nurses, doctors and other healthcare team members were not the only ones who had to go through this trying time. It had been the same for parents as well- or probably even more than we believe. At the start, parents’ visiting hours and days were unfortunately greatly limited. Parent-child bonding is a pillar of neonatal care and the limitations brought about by the pandemic had been heart-breaking. But parents had been understanding and grateful that visiting was still possible in some way.

The doors to 24/7 visits may have temporarily been closed, but thanks to innovative and supportive people, our neonatal unit was provided with the vCreate app. This forward-thinking solution enabled nurses to connect the precious little ones with their parents through photos and videos. This has been a source of joy for many mums and dads, especially for those who do not live locally.

Outside of work, the first few months of lockdown was hard to get to grips with. Even grocery shopping was not as convenient as it used to be. Queues had been massive in some supermarket chains and necessities had been hard to come by. You begin to realise the many things that we had taken for granted. Despite these, it had been comforting to see and feel the public’s support for the NHS. I still remember the Clap for the NHS movement every Thursday evenings.

The virus knows no boundaries and it has affected us personally as well—there was news of colleagues, friends and families who were affected by COVID-19. Even an uncle of mine, unfortunately, succumbed to the disease. The tough part had been dealing with the reality my family is halfway across the world. Getting on a plane to the Philippines to be with and comfort them is no longer straightforward. Communication apps became even more essential- something which I could very much relate to with the babies’ families.
There is a light at the end of the tunnel though. Life has not gone back to ‘pre-COVID’ normality. But we are learning more about the virus and adapting accordingly. For the mums and dads of sick or premature babies, the good news is that they can now visit them any time, although separately.

The pandemic has no set end date, but rays of hope have been seen and hope is something that is very much needed.

Alicia Donovan, Enhanced Neonatal Nurse Practitioner (ENNP) University of Plymouth Hospital, England

When I was six, I had to have my tonsils removed. Since that day, I have always wanted to be a nurse. The sister who looked after me had such a kind face and manner, a crisp uniform with a hat and waist buckle belt. She made me feel like she cared, like I was worth her time and I looked up to her, I knew she was who I wanted to be.

Cut to February 2003, I’m starting my training to become an adult trained nurse. This wasn’t easy and it took me longer than I expected to get my Diploma, but when I finally achieved it, I was so proud. I had reached my life-long goal to date and was in for the long haul.

My first five years were spent in adult neuro intensive care. During this time, I cared for a pregnant lady with a brain injury, who went into preterm labour. After a c-section, the neonatal sister brought her new son down to visit whilst she was still sedated and on a ventilator. There was so much equipment on wheels – incubator, ventilator, pumps, you name it, it was there – but the sister was so calm, kind and baby oriented amidst the chaos. I did not know what was happening, but I was fascinated by this small baby nestling up to his mum’s chest to try to breast feed, mouth wide open. I asked the sister ‘any jobs going where you work?’.

After I finished my four nights with his Mum, I visited the NICU educator, enquiring about how to get a job. Low and behold a job became available a couple of weeks later and I jumped at the chance. Shortly after I left Neuro ICU to join NICU team.

Flash forward to March 2020. I have completed my special care module, QIS training, mentorship training, joined the transport service and became one of the first of 3 ENNPs at the University of Plymouth Hospital.

Then suddenly…COVID-19 starts to appear on the news. At first, I thought nothing of it, it’s just a bad case of flu. I’ve even had a strain of it before, and despite making my asthma flare up and landing me a short stint in hospital, I got over it and lived to tell the tale. Why should I be worried? I’m a nurse – I’ve been through worse.

Then the stories started to flood in. The risks to asthmatics were like nothing we’ve seen. I didn’t want to be a ‘vulnerable person’ but according to the news, GOV and risk assessments, that’s exactly what I am.

So now I am at home. Not working as nurse, transport or as an ENNP. Instead I am shielding to protect myself. This hits me hard, harder than I could possibly imagine, more than any the other issue I’ve have had to deal with. I’ve survived cancer, pregnancy loss, family loss, asthma. But COVID-19 knocks me down in a way I never expected. Since childhood, I have always helped, saved, cared for strangers and loved ones and now I can’t. I’ve got to do what lots of nurse’s struggle to do – care for myself, put myself first. I was not prepared for that.

Watching the news, reading about it online, hearing it all on the radio as I ‘worked from home’ made me feel guilty – guilty for not being able to help, guilty for not being part of the team (I was asked to return back to adult ITU to prepare and care for the potential patients that would arrive, but I couldn’t), guilty for not being there to support my co-workers, friends and family. The guilt was overwhelming and at week 6, I crumbled.

When I participated in the BAPM COVID-19 webinar, my emotions were running wild. I realised I needed support as all this was taking a toll on my mental health. I reached out to my line manager and the NICU Senior Sister, spoke to the mental health COVID-19 support team and I broke down – toxic guilt had taken over and I needed to open my eyes to the truth. The mental health team were amazing, set me back on track and made me see that I am still a nurse, will always be a nurse – as long as I look after myself. I had to let go of the guilt, I was not working but I was still saving lives and my own. I was not going to become a statistic; I wasn’t going to put the strain on the NHS and pressure on the ITU team and ONE day I will be able to return to my team back on NICU. I was honest with my manager and NICU sister, a small support group was created with our unit mental health support lead, allowing for others to speak up honestly and freely. The guilt it seems, was felt by us all and we were all adjusting to it differently. But together, we stayed safe, we stayed strong and we are still able to care, nurse and look after those who will need us when we come back.

So, I am at the start of week 15, completed many, many packages of e-learning, written some guidelines, attending meetings, REaSoN, completed Rotas, kept myself busy with tasks shared out by my colleagues who are still practicing. I have learned to forgive myself for not ‘nursing’, but I am still a nurse, now with more I.T and management skills then before and hopefully sometime soon, I can be back doing what I love the most.

COVID-19 might always be around, but so will nurses, ENNPs, ANNPs, doctors, physios, cleaners, cares, psychologists, occupational health, x-ray, managers, police, fire officers, the list goes on and on. For we are all part of one massive team, one massive family, always working together, saving lives and our own.

Working as a healthcare manager during COVID-19

I am the manager of a 45-bed single-family room Neonatal Intensive Care Unit (NICU) (Figure 1) in Halifax, Nova Scotia, Canada. Before becoming the manager of our unit, I was the clinical lead for our redevelopment to single rooms and was hugely influenced by the care models in Sweden, Norway and Estonia and had visited several of their NICUs to inform our design. I believe in family-integrated care with everything I have. I believe that NICU babies will have better outcomes when their parents are full participants in the care. Being a part of building our new unit, I never expected to have this deeply engrained belief challenged in the way that it was during the first wave of the COVID-19 pandemic.

FIGURE 1

We first felt the impact just before March break 2020. We busily did everything we needed to do to prepare for adequate personal protective equipment (PPE). N95 mask fittings were a priority but there was a shortage of masks and only a fraction of the NICU staff was fit tested. We also went through a very distressing time where some of the PPE was going missing. This required additional oversight to ensure that we had everything that would be required to keep the healthcare workers safe. We ran simulations for donning and doffing. We collaborated with one other health authority in the province. We asked our colleagues at other health centres across the country and even internationally what they were doing when it came to PPE. In the end, we felt ready.

While we were figuring out our PPE requirements, we were also creating clinical pathways to outline the care requirements of patients that were suspected or confirmed for COVID-19. This was a lot of work and the workload remained heavy for months. Our medical director (a Neonatologist) spent countless hours to ensure that our clinical pathways were evidence-based. Once he would have a suggestion, we would book time with our Infection Prevention and Control (IPAC) colleagues to gain their input. We often had to collaborate with other teams, such as obstetrics, postpartum, and transport to make sure that our pathways did not conflict with theirs. To this day he and I are often the first call whenever there is a question about the clinical care of a suspected COVID-19 patient as everyone knows that we are the ones that know these pathways inside out.

As a manager I needed to also make sure that the unit had staff. Things worsened throughout the second half of March with a state of emergency called on March 22nd. A provincial lockdown was in place. Anyone with signs of illness couldn’t come to work. All schools and childcare facilities were closed, and nurses needed to have their schedules adjusted. The one bright side was that everyone wanted to cancel their vacations which certainly helped as nurses became unavailable! It was another thing to worry about for sure.

There was so much fear during this time. None of us knew what was going to happen. One senior nurse in our unit came to me with tears in her eyes. She said, “I am actually angry at myself, that I am a nurse. I cannot believe that I am about to put my husband, my children, all of them at risk, all because of what I do for a living”. It was heartbreaking to see. Also breeding that fear was the decision by the hospital to house the pediatric pandemic response unit in our NICU. Patients were being admitted that were suspected of COVID-19 and there were NICU babies only a couple of rooms over. Some of the NICU babies were displaced to an open-bay ward to accommodate this decision. There was a high level of uneasiness all around.

March 23rd. The absolute worst day of all. The hospital decided that pediatric patients could only have one support person. I was the one that delivered this message to the NICU families. Dads looked at me with tears streaming down their face. Begging to stay. Telling me that they would never leave if they could only be there for their partner and baby. One Mom was so angry, “You have told me that I should lean on “my person”. He is my person and now you are saying that he cannot be here”. It was awful. Especially because I am the one that I told you about in the beginning, the one that believes in families being with their children, about the positive impact that has. I never thought that I would ever see the day when families could not be families. I cannot talk about that day without tearing up. I think a lot about the trauma that was caused. I think a lot about the damage that we caused. The weight of that one day is like no other.

The best things that came from the pandemic were the advancements in technology. Everything happened so fast! Getting certain staff to work from home, getting things in place for families to have a virtual connection in the absence of physical connections. And our hospital fed all the support people which was tremendous!

It has been a long nine months since this all began, and yet, we are so very lucky. The rates in our province have been relatively low. There was the creation of the Atlantic bubble in the summer that helped our community bonds grow. The pediatric pandemic response unit moved out of the NICU. A second support person was able to come back into the NICU which was the biggest win of all!! I yearn for the day when we are fully ourselves again. When the unit is filled with families. When we see siblings holding their new little family member. When the stress of this pandemic is lifted, and we can all breathe again.

Reflections from South Africa

Nkomo
I feel depressed, oppressed, exhausted and with a questionable state of mind; these are ways of describing what I have become during this pandemic. I won’t lie and say I have not thought about quitting. I won’t say I have passion and love for this job at this moment. I won’t say I don’t regret enrolling for a nursing course. I will say this about COVID-19, Corona virus, is driving me crazy.

Nursing is for the strong and when I say strong, I mean emotional, mental and of course physical strength. I mean I wake up every morning to find someone dead. I work in intensive care and death is something you can’t avoid. I have seen people die; I have seen people who are ready to be discharged die; I have declared people dead. Does this mean I am immune to the emotions I feel every time I wrap up a dead baby? Does this mean I am used to it? I won’t say yes but all that it means is that I can tolerate it better.

This global enemy we are battling with has taken our freedom, our family members, acquaintances and most important our sanity. I go to work every morning knowing that there is a possibility I might be a vector of this monstrous virus. I know there is a possibility that one of my colleagues might be sick, that I might lose a friend.

Comfort is non- existent when I’m at work. Wearing the PPE throughout the day is probably the most difficult thing to do at work, 12 hours of discomfort is not a joke.
I watch as people around me test positive, I watch as they get sick, it makes me question my career choice. My career is tough and now that there is an obstacle, I feel as though a piece of me is taken away, I feel as though I am losing myself in the midst of this pandemic.
Nursing is a calling, it’s a sacrifice and it’s a curse in disguise.

Pat
My experience of COVID-19 in the Paediatric Intensive Care Unit (PICU) was that the disease spread was like wildfire. What posed an even bigger challenge is that we were about to engage in warfare with an invisible enemy. The epidemiology was unknown and very much under rigorous studies from the patterns and trends that were observed from China and other countries that were hit by the Virus first.

When COVID-19 entered the South African shores, we were assured that we were ready, and all systems are in place to combat the spread. The readiness came to test immediately into the second month when the scale and the speed of COVID-19 spread rose to high numbers. There was a sudden shortage of PPE and surgical masks. This brought fear and uncertainty. Our nurse’s pledge of service was put to the test, one needed to take a division; to continue to serve without proper protection and stand a risk to contract the disease or quit. In the midst of conflict, we heard reports that our colleagues died in other hospitals. Some of our staff members lost their loved ones at home. The reality hit home because their pain became our pain.

Our PICU got an outbreak of COVID-19. Suddenly 5 members tested positive. This meant that the unit was going to be depleted with a further 6 members of staff who were direct contacts and needed to be quarantined at home for 7 days. During the outbreak, the unit saw a great level of teamwork and dedication. At night, the staff operated with skeleton human resources and really performed beyond expectation amid the fear and uncertainty.
I was in the group that tested positive. In isolation, 14 days felt like 10 years. Not knowing how the virus will spread in the body was nerve-racking along with looking at the news, seeing the death rates rising and at the same time not being 100% sure what was going to happen in the end. When I checked my kids at home, they told me they were all okay. There was nobody to talk to. One relied on video calls to chat with relatives and colleagues at work. We prayed tirelessly, drank lemon juice and ate oranges like they were coming out of fashion.

The COVID-19 outbreak in the unit brought solidarity. The colleagues that remain in the ward took care of us in isolation in many ways; they called to encourage us and to make sure that whatever we needed, was provided for. Even in their exhaustion from being overworked, they encouraged one another to soldier on.

The communication was good relating to the notification of the positive results and what needed to be done. After isolation started, there was no more communication from Human Resource, Infection control or Health and Safety departments. We needed a working committee/ team to constantly check if we were okay in isolation. The team that really looked after us were our Unit manager and colleagues in the PICU. As much as we have acquired ample knowledge about COVID-19, there is still a lot to be learnt about the disease. With all the positive statistics especially relating to recoveries, it becomes easier to look after the patients with COVID-19 provided the correct PPE is provided.

Kasele
In the first instance, I was afraid of being contaminated by COVID-19 but once I started nursing a patient who was COVID-19 positive it came to my mind that I should comply with all the necessary guidance, for me to remain negative and continue to take care of the patient. At this stage, the patient relies on the nurse because this is the only person the patient can see especially when patient is in isolation with no visits from relatives.
The second reason I chose to comply with all the guidance was to protect my family from not being contaminated especially when I know that I have a diabetic husband. It was a big dilemma because I cannot choose my family and abandon my patient. So, as a nurse you just need to adjust, you cannot choose one and sacrifice the other. It was a very big responsibility.

Another experience I had was my patient was young and did not present any symptoms of COVID-19. The patient was asymptomatic but kept in intensive care because of her cardiac condition. The patient condition never deteriorated for us to use all the devices like ventilation, high flow or nasal cannula oxygen therapy. As a team, we were ready for any changes in condition of the patient.

Audrey
My experience during COVID-19 as an overwhelming and heart-breaking experience, especially losing one of our colleagues was traumatizing.

Sandra
The experience I had related to having COVID-19. I started with painful shoulders and I thought it may be might be stress or the medication I was taking for hypertension was not effective. After a week or 2, I started coughing, I had no appetite and I did not know what was happening to me. I thought it was minor flu.

As I was working night duty, I went to the kitchen to grab something to eat. It was 2400 hours. We were busy at work and it was difficult for me as I could not eat. I started feeling dizzy and then I went to casualty to consult the medical and nursing staff. I told the nurse that I had loss of appetite and painful shoulders. The nurse told me I must be isolated. Then they phoned the laboratory sister for me to get a swab for COVID-19. I was asked who I stay with, and was told that I must be isolated, asked whether I wanted to quarantine at home, or I should be taken to where nurses quarantine. I told the sister at casualty, I would rather isolate at home. They told me since they took my details, that I would get the result the same day.

I phoned my sister to fetch my kids before I got home. I drove home after consulting the staff, still waiting for results. I quarantined alone at home the same day I tested. I got the results around 7pm and I had tested positive for COVID-19. I did not know what to do and I informed my family the following day. My mother bought medication for me from the doctor.

It was a difficult moment. I did not know what to do. I have been alone and depressed, but I had to be strong for my kids since I am the only breadwinner. I was always tired; I did not have energy. I was also having diarrhoea and coughing. I managed my COVID-19 experience by quarantining and taking medication, exercise and steaming with mint oil. I also drank lemon water and honey ginger. I ate warm food and took warm fluids. Afterwards, I developed ulcers. At times, both my ears became blocked, but I have overcome that now. The fear I had was to leave my kids. I would wake up at night and pray since I knew how dangerous COVID-19 was. The whole country was affected but I thank God I survived. As a nurse it was not safe at all.

Ruth
I have always loved being a neonatal nurse. It made me feel special because I look after “ANGELS”. The risk of COVID-19 infection from babies is said to be less but we still have to interact with parents who come from home to visit and breast feed their babies. Now that is where the panic set in, because some of the parents would test positive to COVID-19 after interacting with them – making nurses contacts.

Some of my colleagues tested positive and had to quarantine for 14 days leading to staff shortage. Much as I love my job, I kept asking myself why I chose a job that put my life at risk. I live alone and made sure that I didn’t visit my elderly mom; my kids were also not allowed to visit me. My only consolation was coming to work so that I had people who were in my shoes to talk to. There was so much uncertainty about tomorrow.
Some of the nurses were admitted to intensive care and were not doing well. I prayed daily that we did not lose any of them to COVID-19 as this was going to be more devastating- by God’s grace they all survived. I lived in fear, depression gradually sinking in. Watching the world statistics on COVID-19 deaths made it even more scary. I thank God that I did not lose any of my close family members to COVID-19 – though I lost a friend and couldn’t even attend her funeral. The impact of COVID-19 has been devastating and I feel I still have after effects of COVID-19 and require counselling.

Dorcas
My experience during the COVID-19 period as a nurse working in a specialized unit with newborn babies was not too scary, because I don’t believe I can get it from those babies due to their low immature immune system.
I was more worried about life outside the hospital. I was cautious of my environment and the strict limitation to my social life. I was mindful of the need for 100% hygiene standards and my health in general to make sure I did not transport this virus to the babies in neonatal care and to my family. Ways of life really changed but it’s worth it, to stay alive and healthy.
Most of our pregnant mothers were screened before delivery and those not screened were isolated. If they needed to come to neonatal unit, they could not do so until their baby’s test swab was negative; that was the routine along with the PPE worn during the nursing care.

Experience
When this pandemic started in our country as an intensive care nurse, I was very stressed, devastated and scared that I was at risk of getting the virus; I am on the frontline as an essential worker. At the same time, also thinking of the poor neonates as their immune is compromised. I also thought how, if it affects me, I might die, as much as I might protect myself and adhere to the rules of COVID-19.
I still felt that I was not safe enough. As it went, I always read about it and started to understand it more and made sure that I got all the information that I needed to stay safe. The only thing to do during these times was to adhere to the following rules:

  1. Washing hands as often as I can.
  2. Always have my mask on.
  3. As a nurse, always wear PPE.
  4. Always practice social distancing.
  5. Sanitise equipment as required to be safe from the virus.

    As this pandemic hit us, I thought that it was the end of the world, I was scared for my family especially my child and my mom. So, I was praying so hard for God to protect me and my family and everyone out there on the frontline.

Behind the pandemic doors of the NICU

Nurse perspective on Covid19 pandemic at neonatal intensive care unit.

My name is Izabela and I am neonatal and research senior nurse working at Chelsea and Westminster Hospital.
As a critical care nurse, we are prepared to respond for emergencies. Pandemic is an emergency call but without any training. We were asked to act blindly.

Day by day our workplace and roles has changed. We did not have time to analyse the situation because needed to implement mandatory policies, guidelines. We came out of comfort zone.

I have noticed significant changes:

  • Restriction in visiting for parents (one parent allows to visit 9.39-5.30pm after temp check test passed)
  • The unit has been converted to red zone ITU/ green zone HDU and SCBU
  • PPE is mandatory to all staff working on intensive care site (hot and uncomfortable to work, risk of dehydration, prone to UTI etc)
  • Mask fitting challenge (anxiety and stress, some staff is refusing to work in this place, others are having panic attacks or breathing difficulties)
  • All babies remaining inside the incubators (AGP zone)
  • The surgical unit converted to medical and emergency surgical cot created on NICU ITU as a backup
  • Social distancing is almost impossible while team cooperation needed
  • Back on full clinical shifts d=for any CNS and education, research teams (recruitment is on hold but data collection of remaining participants is ongoing)
  • Every unit in the hospital is converted to Covid and post Covid treatment ward
  • Some of the nurses are redeployed in the mortuary (tremendous impact on traumatic experience)
  • Separation from family/friends
  • Staff sickness /rotations/hospitalisation
  • The pandemic has exposed work intensity in isolation.
  • We are all having families, friends and our own kids.

    Adjustment to patient needs became a priority. This arises from stress and uncertainty. Working on the frontline open a question to many of us how safe we are, how we can protect our love ones and if last will should take place?

    We still questioning if we are ready? For how we can go like that? More question is coming every day but there is no answer for most of them.

    I am delighted to be a research lead on our unit but I do feel useless in this field with Covid19. Scientist across the world are working day and night to protect nations. I only observed that none of the admitted babies tested positive which is very good news. We are trying to understand the phenome of biological protection of newborn.

    As senior staff, we are trying our best to support others: junior nurses, doctors, parents. But we do need to think about our mental health as well.

    We do appreciate public support: clapping, free meals, free car parking, skipping the queue while shopping between shifts, positive wards, emails.

    We learn to stay humble, patient and calm. Because simply, we do have no choice. However, we are pleased that we do have a job as for many of us this is the only income we have. And we all have hope. Hope, that this would not last forever.

    Stay well and safe, Iza